It is not news that there are not enough residency-trained, board-certified emergency physicians (“EM Workforce Stretched, Maldistributed,” ACEP News, November 2011, p. 6). It is not news that residencies do not have enough capacity to fill the gap for the foreseeable future. There are four groups of caregivers providing emergency care in this country: residency-trained, board-certified physicians; non–residency-trained, board-certified physicians; family practice physicians; and midlevel practitioners. My concern and annoyance is that the “elite” residency-trained, board-certified emergency physicians are more than happy to work with midlevel practitioners up to and including 50% of the patient volume, while denigrating work done by workforce-trained emergency physicians. In what logical sphere does it make sense to increase logarithmically the volume of work done by the least trained group and cast aspersions on a group that has more training and more experience? What other group tries so hard to sell itself out to a competing entity? In my small rural ED, 85% of patients are seen by a physician with an average door-to-door time of less than 2 hours. How can larger EDs with half of their patients seen by a midlevel and a much longer door-to-door time claim that they are providing a higher level of care? Of course I believe that specialty training in emergency medicine is ideal. I do not want to see emergency medicine sold out to midlevels. If any evidence-based research shows that midlevels provide better care than workforce-trained physicians, I would be happy to change my opinion. When your family member requires emergency care, would you prefer a family practice doctor with years of experience or a newly graduated midlevel?

Robert Goodwill, M.D.
Fort Madison, Iowa